Introduction

Pathways 2026 Session 3: The Medical Staff Organization Manual/Committee Manual – Essentials & Updates

The “Medical Staff Organization Manual” or “Committee Manual” is one of the most important, but rarely discussed, Medical Staff governance documents. It is often drafted as a standalone policy, outlining the Medical Staff’s existing department structure and medical staff committees (composition, duties and responsibilities, and meetings, reports and recommendations). Revisiting the content of the Organization Manual periodically provides an opportunity for Medical Staff leaders to carefully assess their current departments and committee structures to determine whether they continue to work for the organization.

Medical Staffs that are part of growing systems, or which have recently unified, may want to consider whether the Medical Staff would be better served by committees that represent the entire system (e.g., a system Credentials Committee) and, further, whether any committees (whether specific to the hospital or system-based) should be modified in order to make the work of the Medical Staff more effective and efficient, or to include representation more reflective of the modern Medical Staff (e.g., ambulatory representatives, campus-based representatives).

Topics Covered

The value of a Medical Staff Leadership Council – and its duties and responsibilities;

Pros and cons of a dedicated Practitioner Health Committee. We will discuss the duties and responsibilities that can and/or should be assigned to a health committee, including tips for maintaining a robust committee engaged in active, regular oversight of health issues amongst Medical Staff members and privileged practitioners;

Empowered Medical Staff Peer Review Committees – including the value in removing routine peer review from the MEC’s to-do list and, instead, empowering a multi-specialty committee to manage oversight of the entire peer review process;

Are dedicated Advanced Practice Professional Review Committees necessary or recommended? Who should sit on them? What are their duties? To whom do they report?

The Medical Staff’s responsibility for oversight of graduate medical education (GME) – and what the Medical Staff governance documents should say about that;

Bylaw and policy language acknowledging and supporting the assistance and participation of System and Hospital leaders in Medical Staff credentialing and peer review activities, and authorizing committee chairs and officers to take action between meetings of review committees – to avoid waiving applicable immunity and privilege protections;

The role of the presiding officer in managing meeting logistics, conflicts of interest, and confidentiality.

Who Will Benefit?

The 2026 Pathways program can benefit all of the following:

Medical Staff officers
Bylaws Committee members
Credentials Committee members
Medical Executive Committee members
Medical Staff Services Professionals (MSSPs) and other hospital or CVO personnel who support the Medical Staff
Chief Medical Officers
In-house counsel
Governing Board members
Medical Staff members looking to get more involved in Medical Staff leadership

About HortySpringer Pathways

What is Pathways? It’s a training program for hospital and physician leaders who are looking to develop and enhance the skills they need to manage and oversee the hospital’s Medical Staff. Key features:

FOCUSED
Each Pathways Series is focused on a topic – or “theme” – that health system, hospital, and physician leaders have told us is essential and timely. Avoiding the sound bites and consultant-talk that permeate so many leadership training courses that are on the market, Pathways favors a deeper discussion of the topics at hand and take-home tips that can be implemented right away.

INCLUSIVE
Medical Staff leadership does not occur in a vacuum. While the “self-governance” of the Medical Staff is largely the purview of the organization’s practicing physicians, a multitude of individuals and bodies support and oversee Medical Staff activities: Board members, advanced practice clinicians, health system and hospital administrators, quality professionals, medical staff services professionals, HR professionals, executive recruiters, and more! Pathways web-based format allows organizations to finally make Medical Staff leadership training available to all of these individuals, fostering shared understanding and the implementation of aligned and unified policies, procedures, and leadership strategies across the organization.

ACCESSIBLE
Each Pathways webinar has been designed to require a minimal-to-moderate time commitment and to allow training to be completed from the comfort of your own home or workplace. With four 2-hour web-based training sessions spread over the course of several months, participation in the Pathways leadership program means not having to forego leadership development when time for training is limited or travel is difficult or impossible.

Webinar Disclaimer

The information presented during a webinar and any supplementary materials provided to registrants are intended for educational and informational purposes only. Nothing contained therein is to be considered as the rendering of legal advice for specific cases or circumstances.

No one should act or refrain from acting on the basis of any information presented during a webinar without seeking the appropriate legal or other professional advice on the particular facts and circumstances at issue from a lawyer practicing as permitted by applicable laws, regulations or rules of professional conduct. No attorney-client relationship is formed by registration for a webinar or the use of the supplementary materials.